Patient Referral Form
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Please complete and return this form via email or fax. Our team will follow up within 24 business hours. At Avery Cares, every client is seen, cared for, and treated like family
Patient Intake Referral Form
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Section 1: Patient Information
Gender
Insurance (if applicable):
Section 2: Referring Physician’s Information
Referring Physician’s Information
Requested Services (check all that apply):
Allergies:
Fall Risk:
Advance Directive/DNR on File:
Section 5: Emergency Contact / Primary Caregiver
Emergency Contact / Primary Caregiver (copy)
Section 6: Submission & Signature (Kindly write your first name as signature)
Click to Download Our Intake Refferal Form
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What People Are Saying

Avery Cares truly lives up to its name. Their team treated my mother with such kindness and respect we felt supported every step of the way.

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Linda M

Daughter of a Client

The non-emergency transport was a game changer. Always on time, always professional. I never have to worry about getting to my appointments anymore.

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James R.

Patient

From the first phone call, I knew I was in good hands. They don’t just provide services they provide peace of mind.

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Tasha K.

Caregiver